ACA, Medicaid Expansion, and Cancer Care

Leonard Lichtenfeld, MD: The ACA came into being in no small part because of the problems that cancer patients faced getting care. And I will say that I take a certain amount of pride in the fact that the American Cancer Society did the research to demonstrate that and then got behind it—not so much a particular bill, or whatever the ACA became, but the concept that we needed to care for folks who had cancer because the bankruptcy rates were phenomenal.

We had developed evidence that showed if you had insurance, your opportunity for a better outcome was improved: It was with insurance compared with Medicaid or no insurance. Now, the Medicaid, in no small part, is because of people who come into the hospital who have cancer and then are given Medicaid. So, it wasn’t that they had Medicaid and had the benefit of insurance. And there’s little question, based on the studies and the evidence that we have, that over time, people who had more access to care had better access to screening because screening is covered at no cost to the individual.

There’s obviously a cost to it, but the people are taking advantage of that opportunity. Actually, the American Cancer Society just published a report, released last week or the week before, that talked about the cost of cancer care and compared someone with the ACA plan versus the employer plan versus the Medicare plan. And there’s no question that the out-of-pocket costs are still substantial. They still begin every January 1, but cancer patients, unfortunately, go through that deductible pretty quickly.

So, we still have a problem with the deductibles because I do know that most people are having trouble paying those deductibles. They don’t have that $5000, $6000, or $7000, whatever the number may be based on a plan, sitting in their pocketbooks that they can just go ahead and pay. There’s that issue. However, when you look at the larger picture, now they do have access to care; they do have access to medications they never would have had before, and that’s clearly a major step in the right direction.

No one knows what the future’s going to hold for the ACA currently. There obviously have been bills put into Congress. I had the privilege of actually testifying in front of the House Energy and Commerce Committee on the first bill that eventually was pulled. And the testimony I provided on behalf of the American Cancer Society talked about access to care and situations where people should not lose their coverage, where the banned ratings would make a real impact on cancer patients who, for the most part, are older folks. When I say the bans, I mean the amount of money the insurance company can charge an older person versus a younger person. Now that ratio is 3:1. It can go up to 5:1 or even greater, depending on the state.

These are not simple questions; they’re not easy. We will come to some resolution. Our hope— my hope and the hope of the American Cancer Society—is that we don’t harm cancer patients in the process. Some topics that have come up in the past have been things like the benefit design, the essential benefits. It’s critically important that cancer patients have access to the medications they need. Already with the plans, they have to pay very high co-pays or deductibles that may impact their access to those medications. So, we have to make it better, but we certainly have to be careful not to make it worse.

The evidence that has looked carefully at Medicaid expansion has shown, in those states where it has happened, that patients have had various indicators depending on the particular research project. They had better access to care, so it has made a difference. Other states, particularly Republican states in the South—I happen to live in Georgia—have not expanded Medicaid. So, the access issue is real. These are rural states. They have populations that, from a socioeconomic perspective, are frequently struggling—now, there are some people, obviously, who do OK, but there are a lot of people who don’t. They may be in farming communities. I don’t know how many folks who are watching this have ever gone to the rural parts of South Georgia, but they’re pretty sparse, and there are towns that aren’t doing well economically.

There’s another interesting question that has come up—I’m going to refer to my Georgia experience—and that is the hospital issue. So, hospitals are part of economic development. Hospitals are central to the health of their communities. In Georgia, for example, and elsewhere throughout the country, the absence of Medicaid expansion has meant that hospitals are closing down. And it’s not just cancer care. It may be maternity care, or it may be routine care. Obviously, these small hospitals, the critical-access hospitals, can’t provide all the care, but they’re important parts of that community.

So, Medicaid expansion has really impacted the system in a lot of ways—better indicators of health, more people have insurance. Yes, there are issues, I understand that, but overall, we have the evidence that shows that things are better. Is there a cost? Yes, there’s a cost, and we have to figure out the cost part of this equation—not just for Medicaid but for healthcare in general. We need to make sure we’re doing what we need to do so that we have funds available to do what we should be doing.

And being in the community, you understand very quickly how important that hospital may be, how important it is to have physicians and other health professionals available—that people can get care without having to drive 50 miles, 100 miles, or sometimes 200 miles, especially for cancer care. There are some places in this country where people have to go a whole lot of distance just to get seen by a doctor, just to get their treatment. And we can’t see that system go further backward. We need to make sure that people can get care: if not everything in their own communities, at least at some reasonable opportunities so they have a fighting chance.